The role of cytokines and their antagonists in the treatment of COVID-19 patients.

The coronavirus disease 2019 (COVID-19) has various presentations, of which immune dysregulation or the so-called cytokine storm syndrome (COVID-CSS) is prominent. Even though cytokines are vital regulators of body immunoinflammatory responses, their exaggerated release can be harmful. This hyperinflammatory response is more commonly observed during severe COVID-19 infections, caused by the excessive release of pro-inflammatory cytokines, such as interleukin-1 (IL-1), IL-6, IL-8, tumour necrosis factor, granulocyte-macrophage colony-stimulating factor, and interferon-gamma, making their blockers and antagonists of great interest as therapeutic options in this condition. Thus, the pathophysiology of excessive cytokine secretion is outlined, and their most important blockers and antagonists are discussed, mainly focussing on tocilizumab, an interleukin-6 receptor blocker approved to treat severe COVID-19 infections.

Vaccine-induced immune thrombotic thrombocytopenia after vaccination against Covid-19: A clinical dilemma for clinicians and patients.

The coronavirus disease 2019 (Covid-19) pandemic has had devastating effects on public health worldwide, but the deployment of vaccines for Covid-19 protection has helped control the spread of SARS Coronavirus 2 (SARS-CoV-2) infection where they are available. The common side effects reported following Covid-19 vaccination were mostly self-restricted local reactions that resolved quickly. Nevertheless, rare vaccine-induced immune thrombotic thrombocytopenia (VITT) cases have been reported in some people being vaccinated against Covid-19. This review summarizes the thromboembolic events after Covid-19 vaccination and discusses its molecular mechanism, incidence rate, clinical manifestations and differential diagnosis. Then, a step-by-step algorithm for diagnosing such events, along with a management plan, are presented. In conclusion, considering the likeliness of acquiring severe SARS-CoV-2 infection and its subsequent morbidity and mortality, the benefits of vaccination outweigh its risks. Hence, if not already initiated, all governments should begin an effective and fast public vaccination plan to overcome this pandemic.

SARS-CoV-2-related and Covid-19 vaccine-induced thromboembolic events: A comparative review.

Since the start of the pandemic, thrombotic events have been a well-known and severe complication associated with severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) infection. Nevertheless, the initiation of vaccination programs brought another rare yet highly fatal thrombotic event, vaccine-induced immune thrombotic thrombocytopaenia, which has caused extensive debate regarding the safety of vaccines. This review defines the thromboembolic events following infection and vaccination, identifies their risk factors, describes their pathophysiology, and discusses their management, treatment, and prevention.

Coronavirus disease 2019 (Covid-19) vaccination recommendations in special populations and patients with existing comorbidities.

Vaccination against severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) is a crucial step in ending the current worldwide pandemic. However, several particularly vulnerable groups in the population were not included in sufficient numbers in coronavirus disease 2019 (Covid-19) vaccine trials. Therefore, as science advances, the advice for vaccinating these special populations against Covid-19 will continue to evolve. This focused review provides the latest recommendations and considerations for these special populations (i.e., patients with rheumatologic and autoimmune disorders, cancer, transplant recipients, chronic liver diseases, end-stage renal disease, neurologic disorders, psychiatric disorders, diabetes mellitus, obesity, cardiovascular diseases, chronic obstructive pulmonary disease, human immunodeficiency virus, current smokers, pregnant and breastfeeding women, the elderly, children, and patients with allergic reactions) using the currently available research evidence.

A Large Retrospective Study of Epidemiological Characteristics of COVID-19 Patients in the North of Iran: Association between SARS-CoV-2 RT-PCR Ct Values with Demographic Data.

Objectives: To avoid worsening from mild, moderate, and severe diseases and to reduce mortality, it is necessary to identify the subpopulation that is more vulnerable to the development of COVID-19 unfavorable consequences. This study aims to investigate the demographic information, prevalence rates of common comorbidities among negative and positive real-time reverse-transcriptase polymerase chain reaction (rRT-PCR) patients, and the association between SARS-CoV-2 cycle threshold (Ct) at hospital admission, demographic data, and outcomes of the patients in a large population in Northern Iran. Methods: This large retrospective cross-sectional study was performed from 7 March to 20 December 2020. Demographic data, including gender, age, underlying diseases, clinical outcomes, and Ct values, were obtained from 8,318 cases suspected of COVID-19, who were admitted to four teaching hospitals affiliated to Babol University of Medical Sciences (MUBABOL), in the north of Iran. Results: Since 7 March 2020, the data were collected from 8,318 cases suspected of COVID-19 (48.5% female and 51.5% male) with a mean age of 53 ± 25.3 years. Among 8,318 suspected COVID-19 patients, 3,250 (39.1%) had a positive rRT-PCR result; 1,632 (50.2%) patients were male and 335 (10.3%) patients died during their hospital stay. The distribution of positive rRT-PCR revealed that most patients (464 (75.7%)) had a Ct between 21 and 30 (Group B). Conclusion: Elderly patients, lower Ct, patients having at least one comorbidity, and male cases were significantly associated with increased risk for COVID-19-related mortality. Moreover, mortality was significantly higher in patients with diabetes, kidney disease, and respiratory disease.

Dermatological manifestations associated with COVID-19: A comprehensive review of the current knowledge.

Coronavirus disease 2019 (COVID-19) caused by severe acute respiratory syndrome coronavirus-2 (SARS-CoV-2) has become a significant health problem globally. The virus has spread widely and become a global pandemic. The pathophysiology for SARS-CoV-2 has not been explained clearly. It has been associated with several multiorgan symptoms, among which its dermatological manifestations are of great interest. Primarily, there has been no report of skin features among COVID-19 patients. Nevertheless, recently there have been several reports regarding COVID-19 patients who presented with cutaneous manifestations. In the current review, we focus on the various cutaneous manifestations of COVID-19 infection.

Toxoplasma infection and risk of epilepsy: A case-control study of incident patients.

We performed an age matched case-control study of incident epileptic patients to assess the relationship between Toxoplasma gondii seropositivity and epilepsy. Cases were 94 newly diagnosed patients (mean age, 36.7 ± 15.9) with unprovoked convulsive epilepsy of unknown etiology and controls were 88 healthy individuals (mean age, 37.5 ± 17.1) with no history of epilepsy or neurological disorders. Sera of all subjects were examined for anti-Toxoplasma IgG antibodies using commercially enzyme-linked immunoassays. We calculated odds ratios (ORs) and 95% confidence intervals (CIs) using univariate analysis and logistic regression, adjusted for potential confounders. The prevalence of anti-Toxoplasma IgG antibodies in epileptic patients (68.1%; 95%CI, 57.6-77.3%) was significantly higher than healthy controls (47.7%; 95%CI, 36.9-58.6%), indicating a significant relationship between Toxoplasma infection seropositivity and epilepsy (adjusted OR, 2.58; 95%CI, 1.16-5.72; P value < 0.05). The univariate analyses showed more than two-fold higher Toxoplasma seropositivity in patients with focal (OR, 2.31; 95%CI, 0.94-5.67) and generalized (OR, 2.35; 95%CI, 1.215-4.57) seizures versus healthy controls. Our findings support hypothesis that Toxoplasma infection/exposure may play an important role in development of epilepsy. Preventive measures to control of Toxoplasma infection especially in north of Iran and early treatment might be effective to reduce the occurrence of epilepsy in this region.

Diagnostic methods for Helicobacter pylori infection: ideals, options, and limitations.

Helicobacter pylori (H. pylori) resides in the stomach, colonizes gastric epithelium, and causes several digestive system diseases. Several diagnostic methods utilizing invasive or non-invasive techniques with varying levels of sensitivity and specificity are developed to detect H. pylori infection. Selection of one or more diagnostic tests will depend on the clinical conditions, the experience of the clinician, cost, sensitivity, and specificity. Invasive methods require endoscopy with biopsies of gastric tissues for the histology, culture, and rapid urease test. Among non-invasive tests, urea breath test and fecal antigen tests are a quick diagnostic procedure with comparable accuracy to biopsy-based techniques and are methods of choice in the test and treatment setting. Other techniques such as serological methods to detect immunoglobulin G antibodies to H. pylori can show high accuracy as other non-invasive and invasive biopsies, but do not differentiate between current or past H. pylori infections. Polymerase chain reaction (PCR) is an emerging option that can be categorized as invasive and non-invasive tests. PCR method is beneficial to detect H. pylori from gastric biopsies without the need for the cultures. There is no other chronic gastrointestinal infection such as H. pylori with a set of comparable diagnostic methodologies. Despite the availability of multiple diagnostic methods, it remains unclear on the choice of any one method as the gold standard for detecting H. pylori infection, especially in epidemiological studies. In this work, we review the principal diagnostic methods used to detect H. pylori infection and their advantages and disadvantages, and applications in clinical practice.

Brucellosis as a rare cause of olecranon bursitis: case-based review.

A 51-year-old man shepherd presented with mild pain and swelling of the right posterior aspect of his right elbow. In ultrasonography, the affected bursal space had swelling and effusion. Moreover, the aspiration of the affected bursa revealed an inflammatory profile. Brucella melitensis was detected in aspirated fluid and blood cultures. The serum agglutination test (SAT) and 2-mercaptoethanol test for brucellosis were also positive. Therefore, the diagnosis of brucellar olecranon was confirmed. Treatment was initiated using gentamicin for the first 7 days and doxycycline plus rifampicin for 2 months. After treatment, all clinical signs and symptoms were resolved. No relapse was seen after 1 year of the completion of treatment. Clinicians should pay attention to the symptoms of olecranon brucellar bursitis that is similar to that of pyogenic bursitis.

Joint modeling of longitudinal and competing risks for assessing blood oxygen saturation and its association with survival outcomes in COVID-19 patients.

BACKGROUND: The objective of the present study is to evaluate the association between longitudinal and survival outcomes in the presence of competing risk events. To illustrate the application of joint modeling in clinical research, we assessed the blood oxygen saturation (SPO2) and its association with survival outcomes in coronavirus disease (COVID-19). MATERIALS AND METHODS: In this prospective cohort study, we followed 300 COVID-19 patients, who were diagnosed with severe COVID-19 in the Rohani Hospital in Babol, the north of Iran from October 22, 2020 to March 5, 2021, where death was the event of interest, surviving was the competing risk event and SPO2 was the longitudinal outcome. Joint modeling analyses were compared to separate analyses for these data. RESULT: The estimation of the association parameter in the joint modeling verified the association between longitudinal outcome SPO2 with survival outcome of death (Hazard Ratio (HR) = 0.33, P = 0.001) and the competing risk outcome of surviving (HR = 4.18, P < 0.001). Based on the joint modeling, longitudinal outcome (SPO2) decreased in hypertension patients (ß = -0.28, P = 0.581) and increased in those with a high level of SPO2 on admission (ß = 0.75, P = 0.03). Also, in the survival submodel in the joint model, the risk of death survival outcome increased in patients with diabetes comorbidity (HR = 4.38, P = 0.026). CONCLUSION: The association between longitudinal measurements of SPO2 and survival outcomes of COVID-19 confirms that SPO2 is an important indicator in this disease. Thus, the application of this joint model can provide useful clinical evidence in the different areas of medical sciences.

Mistreatment with maggot therapy in diabetic foot ulcer causing an amputation.

Maggot therapy is one of the treatments used in diabetic foot ulcer management. But if we do not pay attention to the indications and contraindications of it, there might be a failure in the treatment.

Clinical misdiagnosis of influenza infection with a confusing clinical course: A case report.

A 32-year-old woman with a history of hypothyroidism and major depressive disorder was admitted with severe weakness and somnolence. She had tachycardia and hypotension, indicative of severe dehydration, and was treated with a vasopressor and sodium bicarbonate, but her clinical manifestations deteriorated. A high-resolution computed tomography (HRCT) scan showed a patchy ground glass appearance with interlobular septal thickening, suggesting pneumonia. Reverse transcription-polymerase chain reaction (RT-PCR) was requested for the influenza A virus (IAV), which was positive. The patient was treated with oseltamivir and discharged with improved clinical symptoms.

Lyme neuroborreliosis: A case report.

Key Clinical Message: Lyme neuroborreliosis is the manifestation of Lyme borreliosis that impacts the nervous system. It gives rise to various neurological and psychiatric conditions, and its diagnosis is challenging. The timely administration of antibiotics is effective. Abstract: A male patient, aged 55, was admitted to the emergency department due to the sudden onset of tonic-clonic seizures. All standard laboratory examinations yielded unremarkable outcomes, except a favorable Wright and 2-mercaptoethanol test. The examination of cerebrospinal fluid revealed the presence of 380 white blood cells per milliliter. The protein level was also elevated, while the glucose level was within the normal range. The results of the serologic tests indicated the presence of both IgG and IgM antibodies to Borrelia burgdorferi. Following the administration of ceftriaxone, a significant improvement was observed in the patient's medical status, and he was subsequently discharged. Lyme neuroborreliosis is the manifestation of Lyme borreliosis that impacts the nervous system. It gives rise to various neurological and psychiatric conditions, and its diagnosis is challenging. The timely administration of antibiotics is effective in treating patients.

Mortality in ICU COVID-19 Patients Is Associated with Neutrophil-to-Lymphocyte Ratio (NLR): Utility of NLR as a Promising Immunohematological Marker.

Background: Achieving a suitable medical laboratory index is very important for the prediction of clinical outcome of COVID-19 patients hospitalized to the intensive care unit (ICU). The correlation between neutrophil-to-lymphocyte ratio (NLR) and unfavorable outcome of COVID-19 patients hospitalized to ICU was the aim of this study. Methods: We evaluated a cross-sectional study of 312 COVID-19 patients who were hospitalized to the ICU (confirmed by PCR and CT-Scan), in Babol city, Mazandaran province. WBC, RBC, lymphocyte, neutrophil, monocyte, platelet count, NLR, C-reactive protein (CRP), ESR, MCV, MHC, and other factors were evaluated. Results: Our findings indicated that all patients aged 56 to 69 years with COVID-19 had a significant difference (P < 0.05) in neu, lymph, PLT count, NLR, ESR, Hb, and CRP. Also, NLR was significantly (P < 0.05) correlated with the death or discharge of the ICU hospitalized patients. The cut-off of NLR was 7.02 and the mean of NLR was 11.3 ± 10.93 and 5.8 ± 7.45 in death and discharge COVID-19 patients hospitalized to ICU, respectively. ROC curve indicated that, for NLR, the area under curve was 0.76. Conclusions: Our findings showed that NLR can be utilized as a clinical laboratory predictive parameter for mortality of COVID-19 patients admitted to ICU.

SARS-CoV-2 Omicron (B.1.1.529) Variant: A Challenge with COVID-19.

Since the beginning of the coronavirus disease 2019 (COVID-19) pandemic, there have been multiple peaks of the SARS-CoV-2 (severe acute respiratory syndrome coronavirus virus 2) infection, mainly due to the emergence of new variants, each with a new set of mutations in the viral genome, which have led to changes in the pathogenicity, transmissibility, and morbidity. The Omicron variant is the most recent variant of concern (VOC) to emerge and was recognized by the World Health Organization (WHO) on 26 November 2021. The Omicron lineage is phylogenetically distinct from earlier variants, including the previously dominant Delta SARS-CoV-2 variant. The reverse transcription-polymerase chain reaction (RT-PCR) test, rapid antigen assays, and chest computed tomography (CT) scans can help diagnose the Omicron variant. Furthermore, many agents are expected to have therapeutic benefits for those infected with the Omicron variant, including TriSb92, molnupiravir, nirmatrelvir, and their combination, corticosteroids, and interleukin-6 (IL-6) receptor blockers. Despite being milder than previous variants, the Omicron variant threatens many lives, particularly among the unvaccinated, due to its higher transmissibility, pathogenicity, and infectivity. Mounting evidence has reported the most common clinical manifestations of the Omicron variant to be fever, runny nose, sore throat, severe headache, and fatigue. This review summarizes the essential features of the Omicron variant, including its history, genome, transmissibility, clinical manifestations, diagnosis, management, and the effectiveness of existing vaccines against this VOC.

A review of the potential neurological adverse events of COVID-19 vaccines.

Despite the advantages of getting access to the coronavirus disease 2019 (COVID-19) vaccines, their potential ability to induce severe adverse events (AEs) has been a significant concern. Neurological complications are significant among the various adverse events following immunization (AEFI) due to their likely durability and debilitating sequelae. Neurological AEs following COVID-19 vaccination can either exacerbate or induce new-onset neuro-immunologic diseases, such as myasthenia gravis (MG) and Guillain-Barre syndrome (GBS). The more severe spectrum of AEs post-COVID19 vaccines has included seizures, reactivation of the varicella-zoster virus, strokes, GBS, Bell's palsy, transverse myelitis (TM), and acute disseminated encephalomyelitis (ADEM). Here, we discuss each of these neurological adverse effects separately.

Anticoagulant therapy in COVID-19: A narrative review.

Coronavirus disease 2019 (COVID-19), caused by the severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2), can manifest itself in several ways, including coagulopathy and thrombosis. These complications can be the first and sometimes only manifestations of SARS-CoV-2 infection and can occur early or late in the course of the disease. However, these symptoms are more prevalent in hospitalized patients with venous thromboembolism, particularly those admitted to intensive care units. Moreover, various forms of arterial and venous thrombosis, or micro- or macro-vasculature embolisms, have been reported during the current pandemic. They have led to harmful consequences, such as neurological and cardiac events, nearly all resulting from the hypercoagulable state caused by this viral infection. The severe hypercoagulability observed in patients with COVID-19 accounts for most cases of the disease that become critical. Therefore, anticoagulants seem to be one of the most vital therapeutics for treating this potentially life-threatening condition. In the current paper, we present a thorough review of the pathophysiology of COVID-19-induced hypercoagulable state and the use of anticoagulants to treat SARS-CoV-2 infections in different patient groups, as well as their pros and cons.

The Use of Remdesivir in Patients with COVID-19.

Remdesivir has appeared to be the most effective medication against the severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) infection and is broadly administered to coronavirus disease 2019 (COVID-19) patients around the world. Remdesivir is an RNA polymerase inhibitor with a broad spectrum of antiviral activities against RNA viruses in in-vitro and in-vivo models of SARSCoV, the Middle East respiratory syndrome (MERS), and SARS-CoV-2. Remdesivir is the first Food and Drug Administration (FDA) approved anti-SARS-CoV-2 treatment for adult and pediatric patients and has been used for not hospitalized and have mild-to-moderate COVID-19, and are at high risk for progression to severe COVID-19, including hospitalization or death. However, questions have been raised about the value of remdesivir in treating COVID-19, and governing bodies worldwide have been hesitant to approve this medication. Nevertheless, in the context of the public health emergency and the urgent need for effective treatments for patients with COVID-19, remdesivir has been approved by several authorities worldwide. Here, we discuss the characteristics and applications of remdesivir, and various challenging studies with different outcomes about its efficacy are also reviewed.

Prevalence of Psychological Distress and Posttraumatic Stress Symptoms and Associated Factors in Hospitalized Iranian COVID-19 Patients.

Objectives: To investigate the prevalence of psychiatric symptoms/distress and posttraumatic stress (PTS) and associated factors among inpatients with COVID-19 before discharge from the hospital. Methods: This cross-sectional study was conducted in two teaching referral hospitals in Babol, Iran from July to November 2020. The subjects were inpatients diagnosed with COVID-19 who were clinically stable. Before their discharge from the hospital, the patients completed three questionnaires: demographic data, Brief Symptom Inventory, and Primary Care Post Traumatic Stress Disorder Screen for Diagnostic and Statistical Manual-5. Results: The subjects were 477 inpatients diagnosed with COVID-19 including 40 (8.4%) admitted to intensive care units. Their average age was 60.5±17.9 years; 53.9% were female. Most had symptoms of significant psychological distress (96.0%) and PTS (8.1%) prior to discharge. A higher level of education (-0.18; standard error (SE) = 0.05; p < 0.001) was a negative predictor of psychiatric distress. The admission to intensive care units (0.86; SE = 0.08; p< 0.001) was a positive predictor of psychiatric distress. Conclusions: Most COVID-19 inpatients suffered significant psychiatric distress and PTS symptoms before discharge. Appropriate mental health crisis interventions are recommended for COVID-19 patients during hospitalization.

Tuberculosis arthritis of ankle: A case report.

Tuberculosis (TB) primarily involves the respiratory tract, but any organ in the body can be affected. In recent years, extrapulmonary TB cases have significantly increased due to the prevalence of immunocompromised patients. Here, we report a case of unilateral ankle arthritis due to Mycobacterium tuberculosis infection.